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Regulated Medical Waste PagffRAaAtIG DOCUMENT 8304366 CODE AREA UN3291 , Regulated Medical Waste, n.o.s., 6.2, PGII 2277 aT' SYSTEMS COMPANY NAME TELEPHONE NUMBER CHCF-California Heath Care Facility (209) 467-4661 ADDRESS p 7707 S. Austin Rd Stockton, CA 95215 E- I certify that the information provided is true and correct, and that the generated materials are properly classified, described, w packaged, labeled/placarded; and are in proper condition for transportation according according to the applicable regulations of the U.S. Department of Transportation. �%` Able G 05-15-2025 10:23 AM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE INITIALS REGISTRATION NUMBER NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE Anthony Jenkins AJ 5039 COMPANY NAME TELEPHONE NUMBER cc w Med-Waste Systems, LLC (818) 998 5533 I— M ADDRESS DATE MEDICAL WASTE COLLECTED CL a 4882 McGrath St Suite 320 Ventura, CA 93003 05-15-2025 10:23 AM z Pharm waste 8 gallon Pharm waste 18 gallon Q p cool, wq p p coot. W p p coot, :Iwt.p p coot, wt.p q cunt, wt.p cc 5 63 > I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that < falsification of this tracking document may result in forfeiture of m trans porter's registration and/or the privilege of utilizing State-authorized facilities. ¢ 9 Y Y P 9� P 9 9 a Anthony Jenkins 05-15-2025 10:23 AM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE F77 ION; NAME REGISTRATION NUMBER N NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Lu Anthony Jenkins AJ TS-167 W COMPANY NAME TELEPHONE NUMBER N (Stockton) Med-Waste Systems, LLC (818) 998-5533 z ¢ ADDRESS DATE MEDICAL WASTE COLLECTED 4079 Cherokee Rd Stockton CA 95215 1 05-15-2025 6:55 PM z Pharm waste 8 gallon Pharm waste 18 gallon 0 p cons. wt.p p cont. v t.p p coot. Wt.p p cunt. wt.p p cant. It.p P 5 63 101 ¢ N I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that or w falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. Anthony Jenkins 05-15-2025 6:55 PM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE } COMPANY NAME TELEPHONE NUMBER I— Healthwise Services (559) 834-3333 J V ADDRESS w 4800 E Lincoln Ave Fowler CA 93625 w PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED LL TSOST-89 05-22-2025 7:57 AM 164.00 In z¢ DISCREPANCY INDICATION SPACE I— z I certify that I have been authorized to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the w requirements outlined in that authorization. w Jorge A 05-22-2025 7:57 AM I' NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency, call ( 818 ) 998-5533 (24-hr company or other emergency response group telephone) Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.